Provider Demographics
NPI:1205990561
Name:WILSON, SANDRA MARIE
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:MARIE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RDH
Mailing Address - Street 1:119 QUAIL RUN
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-5308
Mailing Address - Country:US
Mailing Address - Phone:423-542-5272
Mailing Address - Fax:
Practice Address - Street 1:1233 SOUTHWEST AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6596
Practice Address - Country:US
Practice Address - Phone:423-979-4594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDH0000003997124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist